Mesothelioma: Treatment

At Memorial Sloan-Kettering, our team of mesothelioma experts makes treatment recommendations on an individual basis, taking into account the stage of the cancer, the patient's general health, and, for patients with pleural mesothelioma, how well the lungs function. Patients who are otherwise in overall good health and who have early-stage mesothelioma may be treated with chemotherapy, followed by surgery and radiation. Patients who cannot tolerate surgery or who have more advanced disease are generally treated with chemotherapy alone. Memorial Sloan-Kettering is researching novel treatments for mesothelioma, and participation in a clinical trial may be offered.

Chemotherapy

Most patients will receive systemic chemotherapy to treat their mesothelioma. The most commonly used chemotherapy regimen includes two drugs called pemetrexed (Alimta®) and cisplatin. Recent studies have shown that combination of these two chemotherapy drugs can increase survival and improve quality of life in patients with mesothelioma. This treatment is generally given every three weeks along with a regimen of vitamins to decrease toxicity. However, even with this treatment, the survival rates for patients with mesothelioma remain poor, necessitating the development of better therapies to allow patients to live longer with fewer symptoms.

Patients with peritoneal mesothelioma may receive intraperitoneal chemotherapy, in which chemotherapeutic drugs are administered directly into the peritoneum (the membrane that lines the abdominal cavity).

Surgery

For the majority of patients with malignant pleural mesothelioma, disease is limited to the lining of one lung at the time of diagnosis. Most patients require some form of surgery. A thoracoscopy (insertion of a tube with a scope into the chest cavity) may be performed to confirm diagnosis but also may facilitate drainage of pleural effusion, or fluid around the lung.

For patients with pleural mesothelioma, surgery may be performed to remove the pleura, in an operation called pleurectomy/decortication; or for patients with peritoneal mesothelioma, surgery may be performed to remove the peritoneum, in a procedure called a peritonectomy. For patients in otherwise overall good health who have early-stage pleural mesothelioma, surgeons at Memorial Sloan-Kettering may perform a more aggressive and difficult surgery called an extrapleural pneumonectomy, in which the lining of the lung and the entire affected lung itself, along with the diaphragm on the affected side of the patient's body and a portion of the lining around the heart are removed. If the entire tumor cannot be removed, radiation or chemotherapy may be given.

If a patient has a pleural effusion (fluid in the pleural space that can make breathing difficult), physicians may remove the fluid by thoracentesis. In this procedure, performed under a local anesthetic, a doctor withdraws fluid from the patient's pleura. A drain may be left in for a period of time to complete the draining process. Patients with peritoneal mesothelioma may undergo a similar procedure, called paracentesis, in which fluid buildup (called ascites) is removed from the abdomen.

Another procedure may be performed to improve breathing, reduce pain, and prevent fluid from re-accumulating in patients with pleural mesothelioma — this is called pleurodesis. After removing fluid from the pleura, the surgeon will place a small amount of talc or another substance in the pleura using a tiny video camera inserted through a small incision in the side of the chest. This causes the pleura to adhere to itself and reduces fluid buildup around the lung.

Radiation Therapy

Radiation therapy may be used in several situations for patients with malignant pleural mesothelioma. After patients have had their lung removed in an extrapleural pneumonectomy, radiation is administered to the entire chest cavity to decrease the risk of disease recurrence in the chest. In patients with the lung still in place, such as after a pleurectomy or in patients who cannot have surgery, the use of radiation as a secondary treatment is more challenging. It is difficult to deliver adequate doses of radiation to the outside of the lung without damaging the lung itself.

At Memorial Sloan-Kettering, we have extensive experience with the use of intensity-modulated radiotherapy (IMRT) for the treatment of mesothelioma. IMRT uses sophisticated treatment planning and dose delivery techniques to precisely target a tumor and spare normal structures. We have pioneered the incorporation of PET scans into the treatment planning process. Patients receiving radiation usually begin their radiation therapy four to six weeks after surgery and receive treatments once a day, five days a week, for five to six weeks.

Patients receiving radiation usually begin their radiation therapy a month after surgery and receive treatments once a day, five days a week, for six weeks.

Investigational Approaches

New therapies and treatment approaches for mesothelioma continue to be developed and tested at Memorial Sloan-Kettering.  For more information on our latest investigational approaches, visit Our Clinical Trials.